Like many others, I was distressed by the story of two resident physicians who died…
The question in the title is rhetorical: it is a tough time to be a clinician. Today’s physicians, nurses, social workers, and other clinicians face an array of shifts and disruptions to their clinical routines and professional norms. Sometimes the ground seems to move underneath us. Changes to the practice of medicine can feel constructive; they can bolster and support us; they can even exhilarate us. Yet they can also challenge our sense of autonomy, identity, and professional community. They can rattle clinicians’ sense of vitality at work.
Here at UCLA, we have all faced change in the implementation of electronic health records (EHR). While EHR carries immense promise, its introduction can be burdensome. One study found that each patient visit requires more clinician time for months or years after the implementation of EHR.(1) You may have heard of the “4000 clicks per shift” study, showing that ER physicians spend significantly more time entering EHR data than on any other activity.(2) In addition to time, EHR requires clinicians to adjust long-held routines in countless aspects of clinical work, from arranging chairs in the exam room to catching up on lab results. Even as it facilitates collaboration and coordination, EHR can lessen the time we spend face-to-face with one another. An observational study found that interns spend only 12% of their time with patients, and 40% of their time with computers.(3)
But EHR is only one source of demand on clinicians’ time and attention. Many of us have become inured to the inexorable pace of technoscientific advance in medicine. Yet the growing complexity of our treatment choices can be a source of pressure – one must keep up and stay skilled. Patient visits, too, may feel more taxing. The adoption of protocols, practice guidelines, and reminder systems may increase the number of issues you need to address in any single visit. Patients’ access to medical information can increase their expectations and involvement.(4) All of these factors can multiply the number of deliberations and negotiations in a typical day, and they can increase the cognitive and emotional demand of clinical work.
Finally, many clinicians stand at the coalface of structural changes reverberating through medical institutions, such as the unprecedented pace of consolidation in systems of care. Compared to a decade ago, fewer physicians have an ownership stake in their practices and more work as employees. For some physicians, these changes offer exciting opportunities; for others, they feel unwelcome. And, regardless of your practice structure, you may face declining or stagnant reimbursements, and you may experience pressures to care for higher patient volumes.(5)
Undoubtedly you can name other aspects of contemporary medicine that feel difficult. What do we do to cope? To deal with time pressures, we sometimes work long hours or spend less time with patients or colleagues.(6) Simultaneously, to deal with emotional pressures, we may find ourselves withdrawing from those same patients and colleagues. Withdrawal might feel like a way to minimize demands. Yet to the extent that these strategies increase isolation and undermine professional cohesion and sense of purpose, they are known to contribute to burnout.
However, most of us do not retreat; we find creative ways to face change together. Indeed, the fact that you are receiving a monthly newsletter from the Medical Staff Wellness Committee and reading this column reflect your colleagues’ growing awareness that issues of burnout, depression, and isolation among clinicians warrant attention. Today, clinicians who feel overwhelmed or distressed can avail themselves of more resources than ever, from the Staff and Faculty Counseling Center to campus resources like the Mindfulness and Awareness (MARC), the UCLA Recreation FITWELL Program. In the coming year, in this monthly column, I will explore issues relevant to physician vitality — such as burnout and depression — suggest readings, and offer some practical advice that may suit your needs. Please feel free to contact me; I’m eager to hear your feedback.
It is a tough time to be a clinician, but that may be because of the opportunities that come with change. For instance, the emphasis on patient-centered care reminds us that, at the center of medicine, there is always a relationship between a patient and a clinician.(7) At the same time, technology and big data offer new avenues to improve the quality, efficiency, and value of what we do. Expanded access to health insurance should allow us to better serve our patients’ needs. New opportunities for cross-disciplinary teamwork may deepen our sense of community at work. And so on. I hope you are able to remember the youthful idealism that (most likely) brought you into medicine in the first place and that you can still find your own reasons to be optimistic about the future and grateful for the privilege of clinical work.
- Who Will Heal the Doctors? (New York Times, Oct. 2013)
- The Natural History of Recovery for Healthcare Provider ‘Second Victim’ After Adverse Patient Events (Qual Self Health Care, 2009)
- Burnout and satisfaction with work-life balance among US physicians relative to the general US population (Arch Intern Med, Oct. 2012)
- Why are a quarter of faculty considering leaving academic medicine? (Acad Med, July 2012)
- Suicide rates among physicians: a quantitative and gender assessment (Am J Psychiatry, Oct. 2004)
1. Robert H. Miller and Ida Sim. Physicians’ Use Of Electronic Medical Records: Barriers And Solutions. Health Affairs, 2004, 23(2): 116-126.
2. Robert G. Hill, Jr., Lynn Marie Sears, and Scott W. Melanson. 4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED. American Journal of Emergency Medicine, 2013, 31 (11): 1591-1594.
3. Lauren Block, Robert Habicht, Albert W. Wu, Sanjay V Desai, Kevin Wang, Kathryn Novello Silva, Timothy Niessen, Nora Oliver, and Leonard Feldman. In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time?, J Gen Intern Med, 2013, 28(8):1042–7.
4. David Mechanic. Physician Discontent: Challenges and Opportunities. Journal of the American Medical Association, 2003, 290: 941-946.
5. Ann K. Boulis and Jerry A. Jacobs. The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America. ILR Press, 2008.
6. Kenneth M. Ludmerer. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. Oxford University Press, 2005.
7. Michael Balint, The Doctor, His Patient, and the Illness. 2nd Edition. Churchill Livingstone, 2000.